- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,047.13 / $2,187.76
| Professional | | $776.25 | $1,047.13 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $933.25 / $2,137.96
| Professional | | $933.25 | $933.25 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $1,202.26 / $1,949.84
| Professional | | $630.96 | $1,202.26 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,202.26 / $1,445.44
| Professional | | $912.01 | $1,202.26 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,230.27 / $3,548.13
| Professional | | $1,023.29 | $1,230.27 | $3,548.13 |